Basic Information
| Provider Information | |||||||||
| NPI: | 1447578877 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOFFMAN | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 704 LOUISE AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282042128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043723870 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 704 LOUISE AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282042128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043723870 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2010 | ||||||||
| LastUpdateDate: | 05/01/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | S-C31-TA-853 | AL | N | Eye and Vision Services Providers | Optometrist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 152W00000X | 2223 | NC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 12281758 | 01 | CAQH | OTHER | 5918088 | 05 | NC | MEDICAID | NC08591502 | 01 | MEDICARE PTAN | OTHER |